COVID-19 Screening Form

User Guide: COVID-19 Screening Form

Overview

This COVID-19 Screening Form is designed to collect essential health information to help assess potential COVID-19 risk factors. The form is divided into several sections and includes a print functionality for documentation purposes.

How to Use the Form

1. Personal Information Section

• Full Name: Enter your complete legal name (required)
• Date of Birth: Select your birth date from the date picker (required)
• Phone Number: Provide your current contact number (required)
• Email Address: Enter your email (optional)
• Address: Provide your complete residential address (required)

2. Screening Questions Section

Answer all four required questions by selecting either "Yes" or "No":

1. Close contact with a confirmed COVID-19 case in the last 14 days
2. Tested positive for COVID-19 in the last 10 days
3. Currently waiting for COVID-19 test results
4. International travel in the last 14 days

3. Symptoms Section

• Check all symptoms that currently apply to you from the list provided
• If you're experiencing symptoms, use the date picker to indicate when they began

4. Vaccination Status Section

• Indicate whether you're fully vaccinated against COVID-19 (required)
• If vaccinated, provide the date of your last vaccine dose
• Optionally, specify which vaccine you received

5. Declaration Section

• Read the declaration statement
• Provide your signature by typing your full name
• Enter the current date

Printing the Form

• Click the "Print Form" button at the bottom of the page to generate a printer-friendly version
• The print version automatically hides the print button and optimizes the layout for paper

Important Notes

• Fields marked with an asterisk (*) are required
• Provide accurate information to ensure proper assessment
• Consult healthcare professionals if you have symptoms or potential exposure
• This form is for screening purposes only and does not replace medical advice

Technical Requirements

• The form works best on modern web browsers
• JavaScript must be enabled for optimal functionality
• For printing, ensure your printer is properly connected and configured

Data Privacy

• Information entered in this form is not automatically submitted to any server
• Be mindful of privacy when printing or sharing the completed form
• Follow your organization's data handling procedures for health information

If you have questions about COVID-19, consult official health authority guidelines from organizations like the CDC or WHO.